To be, or not to be--that is the question!

Ethico – Moral Aspectof

Nursing Practice

Nelia B. Perez RN, MSNPCU - MJCN

ETHICS DEFINED• Ethics is a study of good conduct, character, & motives & is concerned with determining what is good or valuable for all people

NURSING ETHICS

• A nurse assumes responsibility and accountability for nursing care provided.

•Morals define personal character,

while ethics stress a social system in which

those morals are applied.

VALUES VS VIRTUES• Values are principles,

standards, or qualities considered worthwhile and desirable.• Values are beliefs that a

person or group holds and in which they have emotional investment and heartfelt commitment.

• Virtues, on the other hand, are moral excellencies and qualities of righteousness corresponding to the nature and character of God.

VALUES VS VIRTUES

VALUE SYSTEM

• A value system is a set of consistent ethics value (more specifically the personal and cultural values) and measures used for the purpose of ethical or ideological identity.

• A well defined value system is a moral code.

Value System• A personal value system is held by and applied

to one individual only.• A communal or cultural value system is held

by and applied to a community/group/society. Some communal value systems are reflected in the form of legal codes or law.

Goals of Value-Clarification :

• The goal of "values-clarification" is for you to become fully conscious of influences, and to explore and honestly acknowledge what you truly value at this time in your life.

• Your values are your ideas about what is most important to you in your life What you want to live by and live for. They are the silent forces behind many of your actions and decisions.

Criteria of Values

Choosing:- Freely from alternatives after thoughtful consideration of the consequences of each alternative

Prizing: - cherishing, being happy with the choice ; willing to

affirm the choice publicly

Acting: - doing something with the choice repeatedly, in some

pattern of life

ETHICAL THEORIES

Varieties of Ethical Theory

• Ethical Egoism• Virtue Ethics• Natural Law• Utilitarianism• Deontology• Situation Ethics• …

Ethical Egoism

• Needs no deep exploration• My goals• My wants• My needs• My desires…• All actions (however they appear)– Are self-serving

Virtue Ethics

• Located in character– Not reasoning

• Aristotle’s ethics– ‘golden mean’ eg• Cowardice (too little)• Courage• Recklessness (too much)

– Renewed by MacIntyre in 20th c – Beyond Virtue

• Virtue ethics describes the character of a moral agent as a driving force for ethical behaviour, rather than rules (deontology),consequentialism, or social context (pragmatic ethics), which derives rightness or wrongness from the outcome of the act itself rather than character.

Natural Law (1)

• Everything has a nature – which makes it what it is, governs how it should be and how it should act.

• A good thing is that which is living out its nature– A good wombat does its ‘wombat things’ well– It would be a bad thing for wombats to ride bicycles– (and we would be doing evil to train wombats…)

• There is a purpose, goal (telos) for everything• The goal is meant to be achieved, the theory is

teleological.

Natural Law (2)

• To deny the attainment of the goal is bad• (intrinsically bad – bad in itself)• purpose and potential– If an entity has potential to become…– NL says good actions enable the potential to be

reached (actualised)• We can discover the ‘nature’ of something– Reflection, observation, revelation– Consistent understandings

NL Good points

• There is a purpose and meaning to existence (principles and absolutes)

• Arbitrary behaviour is unjustified/unjustifiable• Absolute goods understood in terms of

‘nature’, realising potential

NL: Bad/unclear points• Is there only one nature for any entity – Male/female– Heterosexual/homosexual

• Is there only one purpose.– Sex for procreation only– Or sex as expression of love

• intimacy • Procreation• Pleasure

• Conventionalism/Static world• Can we be sure we’re right about nature?– Eg evangelicals and the fallen world

Utilitarianism

• Bentham – maximise pleasure, minimise pain• Need a scale of pleasure & pain• Simple arithmetic tells you what to do• Mill – maximise happiness – for the greatest

number• Or good, or justice, or…

Utilitarianism

• Consequentialist – we consider (all) the consequences

• what we should do is what brings the best consequences

Utilitarianism – an Example?

• From Bagaric and Clark “Not Enough (Official) Torture in the World”

• “…a neat little formula. It measures up factors such as whether the person is a terrorist, whether it is probable they have information and how many lives will be lost if that information is not extracted. It then divides that figure by the time available before disaster, multiplied by whether the information can be obtained elsewhere.” (http://www.cageprisoners.com/articles.php?id=7454)

From the article (USFLR 39)

• The variables are • (1) the number of lives at risk; • (2) the immediacy of the harm; • (3) the availability of other means to acquire

the information; • (4) the level of wrongdoing of the agent; and • (5) the likelihood that the agent actually does

possess the relevant information.

Utilitarianism: Good Points

• Scientific• Objective• Repeatable

Util: Bad/unclear points

• Tyranny of the majority• How do we/can we set an accurate scale?• ‘Simple’ Arithmetic?– All consequences?– For every person?– For every course of action?

• Arbitrary – why should we maximise pleasure/happiness/good…

Deontology

• Good will – intention not result– response based on reason/rationality – Not personal desire

• Categorial Imperative has two forms– Universality– Respect for persons

Deontology: Good Points

• There are absolutes, general laws of conduct• They can be discovered by reason• People are of value

Deontology: Bad/Unclear points

• Does reason enable us to discover the good?• How do we prioritise several ‘goods’– Telling the truth– Preserving life– Not stealing

Situation Ethics

• One absolute principle– ‘to love one another as I have loved you’

• Laws in SE are ‘illuminators’• People are central• Situations /contexts are of great importance.• What is the most loving thing to do?

SE: Good Points

• Love (agapé - as Jesus showed)• Centrality of people• Responsiveness to circumstances• A place for principle– (and faith)

SE: Bad points

• The details (as for utilitarianism)• (Mis) understanding of ‘love’• No absolutes

Sample Questions

• “Three major approaches to ethical decision-making are consequentialist (utilitarian), deontological and metaethical”. Taking a controversial issue, present a clear and reasoned analysis of the major principles, concepts and issues associated with one approach to ethical decision making. What are the weaknesses of this approach?

Sample Questions

• Outline the major arguments involved in a debate over a controversial ‘ethical issue’. In choosing a controversial community or global moral issue, ensure that you define what you understand by the terms ‘ethics’ and ‘ethical controversies’. Present a clear and reasoned analysis of the major arguments involved in the debate as well as the major principles, concepts and issues associated with the differing approaches.

Sample Questions• What does it mean to be morally right or wrong? Explain one

approach to what is right in relation to the ethical issue you have studied. (4, 5, 8)

• What do you understand by ‘ethics’ and ‘ethical controversies’? Nominate an ethical issue and use it to critically examine some of the major ‘approaches’ adopted in ethical decision-making. (5, 6, 8)

• Using the example of a current ethical issue critically examine and evaluate at least two of the major ethical approaches that could be adopted in ethical decision-making. (5, 8, 9)

Examinable Criteria• Criterion 4 Use evidence to support a point of view.• Criterion 5 Demonstrate understanding of relevant

terminology.• Criterion 6 Demonstrate understanding and

appreciation of the implications and significance of philosophical or religious positions.

• Criterion 8 Demonstrate knowledge and understanding of religious or philosophical concepts.

• Criterion 9 Critically analyse and evaluate ideas and information.

One nature?

• " Then Mary stood up, greeted them all, and said to her brethren, "Do not weep and do not grieve nor be irresolute, for His grace will be entirely with you and will protect you. But rather let us praise His greatness, for He has prepared us and made us into men." When Mary said this, she turned their hearts to the Good, and they began to discuss the words of the [Saviour].Gospel of Mary Magdalene (http://www.pbs.org/wgbh/pages/frontline/shows/religion/maps/primary/mary.html)

Categorial Imperative (1)

‘Act so that the maxim of your action can be a universal law’

• Are you willing to carry out the rule yourself?

• Can you wish all people would obey the principle you act on?

• Would all rational people of good-will agree?

• Is it self contradictory?

Categorial Imperative (2)

‘Act in such a way that you always treat humanity, whether in your own person or in the person of any other, never simply as a means, but always at the same time as an end.’

• People are rational and therefore have intrinsic worth. The value of a person is not determined by their usefulness.

• Does the action you propose result in USING someone?

ETHICAL PRINCIPLES

Ethical Principles• Autonomy• Responsibility• Respect• Quality of life• Slippery slope• Benefit• Justice• Equity

• Consequences/consequentialism

• Absolutes/standards/principles

• Arbitrary/relative• Ends, Means• Objective, Subjective• Teleology• Duty, deontology• Slippery slope, straw

man, ad hominem

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Ethical Principles

• Autonomy- refers to a person’s independence, self-determination, self-reliance. A patient has the right to make decisions about her/her care. Ex. Signing a consent form for surgery

Autonomy

Means independence and the ability to be self-

directed.

** Incorporates principles of freedom of

choice, self-determination, and privacy.

e.g Consent

(How)

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• It respects the P.T choice of accepting or refusing medical or surgical treatment

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Ethical Principles

• Nonmaleficience - refers to the avoidance of causing any harm to clients. Try to balance the risks and benefits of a plan of care, while striving to do no harm. Ex: bone marrow transplant promises to bring a cure but there may be a long period of pain and suffering.

Nonmaleficence

Is the avoidance of harm.

-When work with client nurses must not cause

injury or suffering by maintaining competency

in clinical practice.

-Promote balance of potential risk included

harms with benefits

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Ethical Principles

• Beneficence- means promoting good or doing good for others. Take positive steps to help others. It helps to guide difficult decisions where the benefits of a treatment maybe challenged by the risk to the client’s well-being or dignity. The best interests of the client must be upheld. Ex: immunization

Beneficence

Refers to taking positive actions to help others.

Or Means doing or promoting good.

Nurses duty to help promote the well-being of

others.

e.g Administer pain medication and dressing

and emotional support and Child’s

immunization.

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Ethical Principles

• Justice- refers to fairness or equity. Clients need to be treated in a manner that they deserve. Ex. Both clients receive the same treatment when being admitted for surgery, fair resources etc.

Justice

Refers to fairness (treat all clients equally and

fairly).

- Relates to the distribution of services and

resources (resource allocation throughout a

society of group).

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-Nurses commonly face issues of justice when organizing care for a group of clients- how much time is spent with each client?(Based on client need).

-Fair distribution of resources.

-Dilemmas arise when resources are insufficient to meet the needs of everyone.

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Confidentiality

Information about a client must be kept private.

-Client’s record is accessible only to those providing

care to that client.

-Discussing clients outside the clinical setting, telling

friends or family about clients must be avoided.

-Medical records may not be copied or forwarded

without a client’s consent.

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*** Breaking confidentiality can be if there is a well-defined reason to share information.

(Benefit outweigh harm).

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What the different between privacy and confidentiality?

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• ( e.g.. Privacy of P.T is cared for when closing the room door when performing nursing care , confidentiality is cared for by not discussing that care with some one that is not a member of that P.T health care team)

Veracity

Means telling the truth.OrAccuracy or conformity to truth.

- Truthfulness may be challenged during the delivery of health care.

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Fidelity

Means being faithful to one’s commitments

and promises.

- Nurse’s commitments to clients include

providing safe care and maintaining

competence in nursing practice.

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RESPONSIBILITY• Refers to the execution of duties

associated with the nurse’s particular role. A nurse who acts in a responsible manner gains the trust of clients & other professionals. A responsible nurse remains competent in knowledge & skills & demonstrates a willingness to perform within the ethical guidelines of the profession.

RESPONSIBILITY (example)

• When administering medications, the nurse is responsible for assessing clients’ need for the drugs, giving them safely & correctly, and evaluating the responses.

ACCOUNTABILITY• Being answerable for one’s own actions. A

nurse is accountable to self, the client, the profession, the employer, and society

ACCOUNTABILITY (example)

• If a wrong dose of medication is given, the nurse is accountable to the client who received it, the physician who ordered it, the nursing service that set standards of expected performance, & society which demands professional excellence.

ACCOUNTABILITY (example cont’d)

• Thus, when an error is made, the nurse reports it and initiates care to prevent further injury. Accountability calls for an evaluation of a nurse’s effectiveness in practice.

ACCOUNTABILITY PURPOSE

• 1. To evaluate new professional practices & reassess existing ones.

• 2. To maintain standards of health care.• 3. To facilitate personal reflection, ethical thought, &

personal growth on the part of health care professionals.

• 4. To provide a basis for ethical decision making.

ETHICAL CODES

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What does a code of ethics do?

• Gives guidance for decision making about ethical matters by providing a set of values that are basic to nursing practice.

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The Code of Ethics

• Provide rules of ethical or moral behavior for every circumstance.

• Offer guidance about which values should take priority or how they can be balanced in practice.

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Values and The Code of EthicsPrimary values that are central to ethical nursing

practice. The 7 values include: 1. Providing safe, 2. Compassionate competent and 3. Ethical care, 4. Promoting health and well-being,5. Promoting and respecting informed decision-

making, 6. Maintaining privacy and confidentiality, 7. Promoting justice and being accountable

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Providing Safe, Compassionate Competent and Ethical Care

• Nurses value the ability to provide safe, compassion, competent and ethical care that allows them to fulfill their ethical and professional obligations to the people they serve.

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Promoting Health and Well Being

• Nurses value health promotion and well being and assist persons to achieve their optimum level of health in situations of normal health, illness, injury, disability or at the end of life.

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Promoting and Respecting Informed Decision-Making

• Nurses provide persons with appropriate information and services so they can make informed decisions. Ensure nursing care is given with informed consent

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Preserving Dignity

• Recognize and respect the inherent worth of each person and advocate for respectful treatment of all persons.

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Maintaining Privacy and Confidentiality

• Nurses safeguard the trust of clients that information learned in the context of a professional relationship is shared outside the health care team only with the clients permission or as legally required or where failure to disclose would cause significant harm.

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Promoting Justice

• Nurses apply and promote principles of equity and fairness to assist clients in receiving unbiased treatment (social justice) and a share of health services and resources proportionate to their needs. Safeguard human rights.

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Being Accountable

• Nurses act in a manner consistent with their professional responsibilities and standards of practice and are answerable for their practice.

THE CODE OF ETHICS FOR FILIPINO NURSES

• First approved in 1982, 5 decades after it was formed in 1922.

• March 21, 1984: PRC adopted the ICN Code of Ethics and subsequentle was approved by the Board on March 21, 1984 pursuant to RA No. 877 and PD No. 223.

THE CODE OF ETHICS FOR FILIPINO NURSES (cont)

• Unanimously approved through BON Resolution No. 633 on March 21, 1984.

THE ICN CODE OF ETHICS FOR NURSES

An international code of ethics for nurses was first adopted by the International Council of Nurses

(ICN) in 1953. It has been revised and reaffirmed at various times since, most recently with this

review and revision completed in 2005.

PREAMBLENurses have four fundamental responsibilities: to

promote health, to prevent illness, to restore health and to alleviate suffering. The need for nursing is

universal. Inherent in nursing is respect for human rights, including cultural rights, the right to life and

choice, to dignity and to be treated with respect. Nursing care is respectful of and unrestricted by

considerations of age, color, creed, culture, disability or illness, gender, sexual orientation, nationality,

politics, race or social status. Nurses render health services to the individual, the family and the

community and co-ordinate their services with those of related groups.

1. NURSES AND PEOPLE The nurse’s primary professional responsibility is to people requiring

nursing care.• In providing care, the nurse promotes an environment in which the

human rights, values, customs and spiritual beliefs of the individual, family and community are respected.

• The nurse ensures that the individual receives sufficient information on which to base consent for care and related treatment.

• The nurse holds in confidence personal information and uses judgement in sharing this information.

• The nurse shares with society the responsibility for initiating and supporting action to meet the health and social needs of the public, in particular those of vulnerable populations.

• The nurse also shares responsibility to sustain and protect the natural environment from depletion, pollution, degradation and destruction.

2. NURSES AND PRACTICE • The nurse carries personal responsibility and

accountability for nursing practice, and for maintaining competence by continual learning.

• The nurse maintains a standard of personal health such that the ability to provide care is not compromised.

• The nurse uses judgement regarding individual competence when accepting and delegating responsibility.

• The nurse at all times maintains standards of personal conduct which reflect well on the profession and enhance public confidence.

• The nurse, in providing care, ensures that use of technology and scientific advances are compatible with the safety, dignity and rights of people.

3. NURSES AND THE PROFESSION

• The nurse assumes the major role in determining and implementing acceptable standards of clinical nursing practice, management, research and education.

• The nurse is active in developing a core of research-based professional knowledge.

• The nurse, acting through the professional organization, participates in creating and maintaining safe, equitable social and economic working conditions in nursing.

4. NURSES AND CO-WORKERS

• The nurse sustains a co-operative relationship with co-workers in nursing and other fields.

• The nurse takes appropriate action to safeguard individuals, families and communities when their health is endangered by a coworker or any other person.

What is a Dilemma?

• A difficult problem seemingly incapable of a satisfactory solution.

• A situation involving choice between equally unsatisfactory alternatives.

Aroskar et al• Perplexing situation.

Merriam Webster Dictionary

Definitions 0f Ethical Dilemmas

• Ethical dilemmas are situations involving conflicting morals claims, and give rise in such questions as :

– What ought I to do?

– What harm and benefit result from this decision or actions?

– What is good (virtue) or what is duty (right)?

Aroskar et al

Bioethical Dilemmas: Life, Death, and Dilemmas In Between

• Definition– Dilemmas that pose a choice between perplexing alternatives in the

delivery of health care because of the lack of a clear sense of right or wrong

– Nurses should consider the dilemmas that might arise in a given practice setting.

Bioethical Dilemmas: Life, Death, and Dilemmas In Between

• Life– Bioethical abortion issue

• When does life begin?• Nurses serving in women’s and children’s health

settings must be prepared to face this morally laden issue.

– Reproduction issue—influenced by genetic screening, genetic engineering, and cloning

Bioethical Dilemmas: Life, Death, and Dilemmas In Between

• Death– Quality of life and definition of death issues: With advances in health

care, what is usual and what is heroic care has become unclear.– Euthanasia and assisted suicide also present new ethical questions.– Nurses in every setting must be prepared to consider end-of-life

questions.

Bioethical Dilemmas: Life, Death, and Dilemmas In Between

• Dilemmas in between– Right to health care• Health care system has become more selective in the

amount and type of treatment offered as a result of managed care.• Is each person entitled to the same health care

package?• Does ability to pay affect specific level of entitlement?• How ethical is gatekeeping in the new managed care

system?• Access to health care and respect for human dignity

are at the core of nursing practice.

Bioethical Dilemmas: Life, Death, and Dilemmas In Between

– Allocation of scarce resources

• Should the recipient of scarce resources be selected on the basis of quality of life? Ability to pay? Best prognosis? First-come, first-served?• Nurses should be prepared to consider questions

regarding allocation of scarce resources.

Ethical Dilemmas in Nursing • The challenge of decision

making .• The sanctity of life vs the

quality of life.• Informed consent• Truth-telling – the question

“am I going to die? This raises important issues about truth telling.

Ethical Challenges

• The challenge of veracity– Issues of alternative treatments and acknowledgment of uncertainty

test truth-telling.– Which treatment among two or more is best for the patient?– Which of the new drugs should be used?– Should every patient be subjected to every possible form of

diagnostic treatment?– Should the patient be made aware of questions and various options

surrounding care?– Is disclosure of uncertainty beneficial or detrimental?

• The challenge of paternalism– Provider tries to act on behalf of the patient and believes that his or

her actions are justified because of a commitment to act in the best interest of the patient

– Interferes with a patient’s right to self-determination

Ethical Challenges

• The challenge of autonomy– Makes way for the crucial legal step of informed consent– When are patients competent to make informed consent decisions?

Can family members or surrogates make decisions by proxy?– Questions about informed consent are raised for minors, confused

elderly, mentally compromised, imprisoned, inebriated, unconscious, and those in emergency situations.

– Nurses also must take responsibility for understanding and educating people about advance directives.

Ethical Challenges

• The challenge of accountability– Nurses have an obligation to uphold the highest standards of

practice, to assume full and professional responsibility for every action, and to commit to maintaining quality in the skills and knowledge base of the profession.

– The obligation to denounce a harmful action or a potentially threatening situation may fall to a fellow member of the profession; to remain silent is to consent to the action of the threatening situation.

Ethical Challenges

VARIABLES AFFECTING ETHICAL DECISIONS

• Because ethical problems occur in situations involving people who have different approaches to “moral reasoning”, it is helpful if the nurse can sort through the various factors that influence a persons’ thinking.

VARIABLES (cont’d)• Emotions• Legal considerations• Cultural diversity• Religious/Spiritual convictions• Education level• Past life experiences• Developmental level

VARIABLES (cont’d)• Societal changes• Race• Gender• Class• Economic level• Sexuality orientation• Current state of “health”

ETHICAL DECISION MAKING METHODS

• Each ethical situation or dilemma will be different, but the nurse in any setting can use the following guidelines for ethical processing and decision making.

METHODOLOGY (cont’d)• Presume good will• Identify all important persons• Gather relevant information• Identify important ethical principles• Propose alternative courses of action• Take action

Situation on Truth TellingA Patient’s Right to Know the Truth

Carolyn , age 21, is dying of leukemia. She wants to know what is happening to her. However, her devoted mother believes in shielding Carolyn from this prognosis. Nurse A believes client, who repeatedly ask about her worsening signs and symptoms, has a right to know the truth. Carolyn’s mother , a wealthy, influential woman, threatens to sue the hospital if her daughter finds out that she is dying.

Situation cont.

Nurse A wishes to support the patient’s right to know the truth. Nurse B wishes to acquiesce to the mothers wishes.As a professional nurse, what would you do in this situation??

Nursing Students’ Experiences

• Resolution of the conflict.

• Rational for resolution.

Conflict about the right thing to do.

Unethical attitudes and behaviors of practicing nurses and doctors.

Questions

SENSITIVE ETHICAL SITUATIONS

• Bio-technology• Surrogate Pregnancy Contracts• Adoption• Abortion• Substance Abuse• AIDS/HIV• Death & Dying• Living Wills/Health Care Surrogates• Organ Donations

To know even one life has breathed

easier because you have lived – this is to have succeeded!

THANK YOU FOR NOT FALLING ASLEEP!